New cause area: Violence against women and girls

Summary

• Globally, one third of women and girls experience violence during their lifetime
• Violence against women and girls (VAWG) has significant health, economic and social effects for survivors, perpetrators and society more broadly.
• There is moderate and growing evidence that interventions that seek to prevent VAWG from occurring are cost-effective
• VAWG as a cause area has moderate absorbency for more funding, with a number of potentially promising avenues for funding
• There are several key uncertainties that were identified in this report, concerning the scalability of interventions in this area, how interventions would be received by communities and governments, and the comparative and additional benefit of directly addressing VAWG versus its risk factors.
• Overall, this report recommends that VAWG be considered as a new cause area.

Disclaimer: This report represents a shallow dive into this cause area; approximately 20 hours was spent on this report. With more time, several of the key uncertainties presented through the article might be addressed, and more time would be spent analysing potential opportunities for new organisations and funders in this space. However, I would anticipate that this is unlikely to significantly change how promising VAWG is as a cause area

How big a problem is violence against women and girls?

Nearly one third of women and girls aged 15 years of age or older have experienced either physical or sexual intimate partner violence (IPV) or non-partner sexual violence globally, with 13% (10–16%) experiencing it in 2018 alone (Sardinha et al 2022). This figure does not include a number of areas, including sexual harassment, female genital mutilation, trafficking in women or cyber-harassment (UN Women). It is also likely that this figure, due to chronic under-reporting, underestimates the true burden of VAWG,

 The Global Burden of Disease, which includes information on IPV but not VAWG more generally, reports it as the 19th leading burden of disease globally- it is responsible for 8.5 million DALYs and 68 500 deaths annually. In several countries, violence against women is in top 3-5 leading causes of death for young women aged between 15 and 29 (Mendoza et al 2018). In addition to the direct harms of VAWG, it is a significant risk factor for other conditions- VAWG is responsible for 11% of the DALY burden of depressive disorders and 14% of the DALY burden of HIV in women (Healthdata.org).  

Globally, the rates of VAWG are both alarmingly high and have slightly increased over the last 30 years, despite gains in other areas of women’s health, such as maternal care (Think Global Health). Further, there are certain countries and regions of the world (e.g. several Asian countries) that have seen significant increases in the rates of VAWG over the last two decides (Borumandnia et al 2020).  The geographical distribution is shown in the figure below, which takes data from the 2018 WHO Global Database and which was published in The Lancet earlier in 2022 (Sardinha et al 2022)

What effects do violence against women and girls have?

Health costs of violence against women

The health consequences of VAWG are significant; they can be immediate and acute, long-lasting and chronic, and/or fatal. Some of the most common health consequences of VAWG are summarised in the table below.

Collating the evidence for the odds ratio (OR) of VAWG for each of these conditions would be valuable but was not prioritised for this shallow report. Instead, here are a select number of statistics related to the health consequences of VAWG:

• Multiple injuries (e.g., broken bones, facial injuries, eye injuries, head injuries, broken or dislocated jaw) were nearly 3 times more likely to be reported in those who experienced past year IPV compared with women who were never abused (OR 2.75; 95% CI:1.98–3.81) (Anderson et al 2015)
• IPV was correlated with an approximately 1.6 OR of suicidal ideation , and a 2.0 OR of depressive symptoms (Devries et al 2013)
• Survivors of VAWG  are significantly more likely than other women to report overall poor health, chronic pain, memory loss, and problems walking and carrying out daily activities (WHO 2005)

Economic costs of violence against women

In 2016, the global cost of violence against women was estimated by the UN to be US$1.5 trillion, equivalent to approximately 2% of the global GDP (UN Women 2016). The economic cost seems to have two major contributing factors:

• Lost economic productivity due to absenteeism and  lost productivity: A study in Ghana (Merino et al 2019) found that for women experiencing any form of violence, the total days of lost productivity was 26 days per woman in the past 12 months. This translated into nearly 65 million days at the national level or equivalent to 216,000 employed women not working, assuming women worked 300 days in the year. Overall, the economy was estimated to lose output equivalent to 5% of its female workforce not working annually due to VAWG. Similar results have been shown in India and Uganda (Puri 2016)
• Increased utilisation of public services: Survivors of VAWG have increased utilisation of public services, including health services, criminal and civil justice systems, housing aid  and child protection costs, as well as specialist services. The European Institute for Gender Equality estimates that this incurs a similar (if not greater) economic cost than lost productivity.

Social costs of violence against women

There are very strong and reasonably self-evident arguments for the social harms of violence against women. The UN  Sustainable Development Goal 5, which focuses on gender equality, includes the elimination of all violence against women and girls (VAWG) by 2030. Due to time constraints, I have not offered a more in-depth analysis of the social costs of violence against women; in lieu of this, I recommend the following resources:

• Bill and Melinda Gates Foundation: A conceptual model of women and girls’ empowerment
• VAWG and Human rights

Even though justice and equity arguments are more difficult to conceptualise and estimate the benefit of (Kapiriri and Razavi 2022), these are strong virtues which a majority of the population value, and which work in this space is likely to be in service of.

What works in reducing the prevalence and harms of violence against women and girls? 

In conceptualising what approaches might be tractable in preventing VAWG, the universal public health model of primary, secondary and tertiary interventions was utilised.

Primary prevention

Several primary prevention programs have shown promising cost-effectiveness profiles. These programs have mostly focused on community activism to change gender norms and attitudes, school and couple-based interventions to focus on transforming gender relationships (What Works). There are three RCTs focused on primary prevention that could be identified through a literature search:

• Community based action teams (RCT in Ghana) - An RCT of a Rural Response System, which uses community based action teams to increase knowledge about VAWG, change individual and community attitudes towards gender equality and violence, positively change gender and societal norms and behaviours, as well as counselling & couple support and better referral systems found a cost per DALY averted of US$52 among female participants.
• Unite for a Better Life  (RCT in Ethiopia)-  An RCT of over 6600 households in rural southern Ethiopia, which had a combined workshop-based and community mobilisation approach (delivered to men, women and couples in the context of a traditional Ethiopian coffee ceremony), reported a cost per year free from physical and or sexual intimate partner violence of US$194 at the community level and US$2726 for workshop participants. This equates to a cost of US$78.4/DALY,
• SASA! Community mobilisation intervention (RCT in Uganda)-  In Uganda,  an RCT of the effectiveness of a community based intervention engaged activists, ssengas (traditional marriage counsellors), drama groups and community  based organisations, training them to plan and run various activities including community dramas, poster discussions, small group activities and one-on one ‘quick’ chats. This intervention found a cost per year free from IPV of US$460, which equates to a cost of US$184/DALY

Overall comments:

• These studies suggest that targeted primary prevention interventions may be cost-effective when purely considering the health effects
• If the economic and social effects, as well as indirect effects on other health domains were modelled, such interventions are likely to look more promising (my subjective estimate is by a factor of 2-5).
• A number of these studies have been published within the last 12-36 months; I am unaware of any other cause area reports into VAWG, but these studies are likely to update towards this cause being more promising.

Secondary prevention

Secondary prevention interventions for VAWG have predominantly focused on screening and early identification of women who are at risk of or who have recently been victims of violence.

• A meta-analysis of screening and referral programs for women who currently or in the past suffered from violence (O’Doherty et al 2014) found that programs found a total of 11 trial; based on these, screening programs increased the identification of IPV (risk ratio 2.33, 95% CI 1.39-3.89), but there was no evidence that screening increased referrals to domestic violence support units and no evidence of reduction in IPV after 3-18 months.
• In their search, the authors identified one study (Feder et al 2011) that conducted an economic evaluation- unlikely to be cost-effective.
• Since then, a few studies have conducted economic evaluations of secondary prevention programs (Devine et al 2012); they found these programs to potentially be cost-effective at a cut-off of £20 000/DALY, and very unlikely to be cost-effective at £1 000/DALY.
• There are several ongoing trials looking at effectiveness and cost-effectiveness of secondary prevention e.g. the HARMONY trial, a multi-centre RCT in Australia

Overall comments:

• Although these studies are undertaken predominantly in a HIC setting with higher implementation costs and slightly lower burden of VAWG, it sees that secondary prevention may be effective, but is is unlikely to cost-effective

Tertiary prevention
 

Tertiary prevention has predominantly focused on the provision of health and other services (e.g. legal, accommodation) to reduce the burden of VAWG that has already occurred. In researching this space, a few key pictures emerged:

• Tertiary services, although undoubtedly important, are in general expensive to run. There may be some exceptions to this e.g. certain types of short-stay housing services.
• There is a lack of explicit cost-effectiveness analysis of such programs, as they are often integrated or sub-programs of existing public services
• Tertiary prevention, certainly within HIC and likely in LMIC as well, receives a significant amount of funding in this space. .

Who is working on this?

There are a number of countries and some international organisations that are funding work to decrease VAWG:

• There seems to be a focus, especially in HIC, on tertiary prevention, with provision of health and other services (e.g. accommodation) for survivors of VAWG receiving a significant proportion. Examples of this include UK data on government funding to tackle VAWG over the last decade shows a fairly constant funding of approximately £40 million pounds/year, focused on tertiary services.
• The major global fund is the UN Trust Fund to End Violence Against Women. It works with civil society organisations to prevent violence, improve access to service and strengthen implementation of laws and policies. Since 1006, it has awarded US$198 million to organisations and partners in this area.
• There are a number of local funders that have their own individual focus (a select list can be found on Charity Excellence Framework). Most of these organisations and funds are small, with individual contracts and grants ranging from US$100-100 000. They do not seem to have capacity to offer medium to large scale grants, such as those required for scaling up or running RCTs.

Overall, for the scale of the issue, it seems like VAWG receives insufficient attention and funding (you can look here for visualisations of where global health funding goes). For instance, even looking specifically within women’s health (which in and of itself is neglected), VAWG is neglected; for instance, the Gates Foundation alone has committed 3.1B dollars towards family planning services within the next 5 years.

What could be achieved with additional investment?

Although there are some funders and organisations working in the space, it seems that there are several gaps in the current landscape, and that this area has moderate absorbency for funders: 

Scaling up prevention programs

A funder could help to scale up prevention programs that have shown early and promising signs of cost-effectiveness from initial RCTs. Based on the above evidence, this is most likely to be community-based primary prevention programs that seek to change gender norms and attitudes. The UK government, in partnership with Raising Voices, Social Development Direct and Care International, started ‘What Works: Impact at Scale’, a 7 year and £46 million pound project that hopes to scale up prevention programs in LMIC that have shown initial promising cost-effectiveness. Despite this, it is likely that: 1. There are likely to be other geographies or programs that are not under the remit of this program, 2. This organisation could be strengthened with additional funding.

More RCTs

Although we have some initial proof of concept for several interventions in this space, it is likely that additional studies to see what works, most likely in primary prevention and secondary prevention of VAWG in sub-Saharan Africa or Asia, would be quite helpful. Indeed, as noted in several reports in this space, a critical challenge is to develop a robust evidence base for impactful prevention that can be rapidly scaled up and sustained within the fiscal limits of LMIC governments and their development partners. The kinds of studies that I would be interested to see here are those that have worked in other global health and development fields, such as mass media campaigns (e.g. radio campaigns) and digitally-delivered interventions. Since RCTs are reasonably expensive to run, the support of a major funder might be pivotal in building a robust evidence base.

Policy advocacy

It seems likely that policy advocacy to encourage governments to institute national action plans for VAWG, and have national action plans that have a strong inclusion of primary prevention interventions, would be impactful.  There are also potentially some direct policy and legislative changes that may have significant impact e.g. the right to divorce without the consent of a husband (Ardabily et al 2011). Although the cost-effectiveness of policy advocacy has not been explicitly modelled in this report, I likely think that encouraging governments to develop robust plans to tackle VAWG is likely to be a cost-effective strategy that is reasonably tractable and a good investment for a funder. However, there is low confidence for this claim,  and further specific research into this would be beneficial.

Key uncertainties

How scalable interventions that aim to reduce VAWG are

It is unclear how context dependent the factors that contribute to VAWG are, and to what extent interventions that work in one context are generalisable. A number of the primary prevention strategies have focused on changing gender-norms in Sub-Saharan Africa; it is unclear to what extent this mechanism would work in other contexts (Bates and Glennerster 2017). In addition, the specific policies and legislative context and environment between countries are likely to be different, and it is unclear how transferable policy asks in one context might be in another.

The complex sociocultural nature and factors that contribute to VAWG may lean towards this issue having different mechanisms in different contexts and therefore being less scalable. 

Although this question was not rigorously addressed due to a lack of time, my initial subjective thoughts on this are:

1. There are likely to be some interventions, particularly wide reaching primary prevention techniques (e.g. mass media campaigns), that are reasonably transferable between contexts
2. This is something that can only be figured out by scaling up, which itself justifies this being a cause area that attracts an influx of funding.

How interventions would be received by communities and governments

Interventions that seek to talk about gender norms or increase access to care for women who are survivors of violence may not always be received positively. There are likely certain contexts within which such programs may not be as effective and perhaps spark outrage and backlash. In light of this, it would be important to :

1. Understand the indirect and flow-on effects of interventions for VAWG; in particular, it would be important to consider and attempt to answer questions like: is there a reactionary increase in VAWG in response to these programs? Is there a reduction in the prevalence of VAWG but an increase in its severity? A thorough consideration of these negative externalities would be necessary to ensure that any intervention is positive and effective.
2. Ensure that interventions are developed in close partnership with local communities (Seward et al 2021). It seems that this might mitigate at least part of this concern and is likely to inherently be a better approach (Horton 2021).

The relative benefit of addressing risk factors

There is some literature that looks at the effects of reducing the burden of VAWG through modifying some of the underlying risk factors and drivers. For example, given that poverty and economic hardship are risk factors for VAWG, providing cash transfers to women, there are some studies that have looked at the effects of cash transfers on rates of VAWG. Another example of this might be programs that seek to reduce alcohol consumption, which is another key risk factor for VAWG. 

The effect of modifying these risk factors on VAWG is inconclusive, and the effect sizes tend to be relatively small. It is likely that even though reductions in VAWG may be a positive externality of other programs, they are unlikely to be cost-effective in preventing VAWG (What Works). Especially given the increasing burden of VAWG, it is likely that direct interventions are likely to be crucial .

Conclusion

Overall, VAWG represents an important cause area. Beyond the deaths it causes, the majority of its burden comes from its other health impacts and its immense economic cost. Over the last decade, there has been significant improvement in the evidence base for interventions preventing VAWG, which may be cost-effective and scalable. Although there are several organisations and funders in this space, including public funders, there seems to be reasonable scope for more work and funding in this area. Based on this shallow report, this report recommends violence against women and girls as a cause area.

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Acknowledgements: I would like to acknowledge the following individuals, who provided feedback on an earlier draft of this report: Ilona Arih, Toby Webster, Abe Tolley

Personal motivation: I was initially motivated to investigate VAWG in part due to my personal and professional interest in the area; as a healthcare worker, I have seen the devastating effects of VAWG in both the hospital and primary care setting. Despite this initial interest motivating an exploration of this cause area, I believe that the report is nonetheless unbiased and balanced.